Kudos for Kevin for linking to an article that brings out one of the real problem’s with this country’s healthcare delivery system.

1. There’s a mistaken impression that EMTALA provides some sort of wonderful safety net for the uninsured. Even when it’s applicable, things are not roses.

2. There’s few mechanisms that the system has (or cares to) help people obtain insurance unless it’s to obtain payment once treatment has started. Where is the outreach by the hospital to sign up Medicaid patients before they’re in a bed?

3. List prices for medical services especially in hospitals are, at this point, nothing more than fraud in many cases. The irony is that 90 – 98% of all uninsured charges will never be paid. Lab tests billed to the poorest members of society at $55 should not be billed to the most wealthy at $6. Standard room rates billed to the poorest at in excess of $2000 should not be billed to the richest at $500.

“Anon 11:27 is the worst kind of ass**** jerk. For those who want civil discourse, you’re not going to get it as long as you stand by and lionize people who make these arguments as respected colleages while excorciating me as a sodomizer. You need to take it upon yourself to censure your “respected colleagues” who lie, distort, and lack all human decency.”

Elliott, I don’t know where this diatribe came from, but Anon 11:27 didn’t use the phrases in his or her comment. I don’t know how you know who that particular person is.
I know you and I have commented in other posts about civil discourse, and yes, it does apply to all of us, physician, attorney and John Q. Public alike. So, again, I ask you, others who agree with your position, along with my colleagues, to knock off the rude, insulting comments.

“”Anon 11:27 is the worst kind of ass**** jerk . . .”

Elliott, it seems no one can outdo your own efforts to make you seem rude, irrational, thoughtless, uncivil, embarrassing and just plain wrong.

Don’t worry about how badly other posters make you look. They can’t touch you.

Anon 11:27 only cares about the pathologists bill? How about the hospital that overcharged her? The ED doc that shamelessly upcoded her? The anesthesiologist charging her for 6 hours of care when he documented less than one?

Since I cannot challenge the ultrasound here, I didn’t. But I did order the records to make sure there was a medical necessity, and once checked, it did not seem unreasonable.

And I ordered the pathologist’s report to make sure the work done rated a level VI charge. Personally, I don’t think a level VI was necessry in this case – the purpose of such an examination would be to make sure everything was discharged. What purpose did the fetal dissection serve? To whom did the report go? Anybody?
Who’s decision is it to do the level VI anyway? And a separate charge for the placenta, BTW.
The difference in price between a level IV and a level VI in this case is @ $200.

I do have an agenda – to make sure everyone can have medical care with equitable charges for equitable service.

But they upcoded, and as noted above, “list” prices for the unisured are outrageously jacked up.

Anon said:

On the 1% chance she had an ectopic pregnancy!

You’re seriously an ED doc, anon? Defensive medicine aside, the whole point of doing these tests is to make sure you don’t miss something big that can kill a patient. I’m pretty sure “ectopic pregnancy” qualifies.

You don’t have the entire story, and you *clearly* have no experience or compassion for people without health insurance.

Do you judge your patients while they’re sitting in the waiting room, or wait until you’re examining them to make gross assumptions about them?

“So tell me – who decided this 14 week fetus needed a $650 dissection?”

Don’t you read? The lawyers did.

“On the 1% chance she had an ectopic pregnancy!”

She pooped out a fetus. If she had an ectopic it would mean she had a heterotopic pregnancy, 1/35,000 according to the literature, though i’m sure ruling it out is the “standard of care” if you practice law for a living. I would have ordered the ultrasound, but only because i’m practicing in the United States of CYA. In Canada, I wouldn’t have ultrasounded her post-SAB. In fact, it would have been impossible, you can’t just call in the tech from home in most Canadian hospitals just to Cover your Ass.

Lin Osborne:

No, all the anonymous posters are not the same poster.

Fraudulent billing implies billing for things that weren’t done. If they were poorly documented, of course there is more difficulty in showing they were done, but that is still not the same as their not having been done. And it isn’t proof of fraud, either. You might have a case for refusing to pay for the billed service absent adequate documentation. Calling the providers fraudulent is going beyond that, though. Sorry, but you should have some standards, too.

Why not stick to the facts you have rather than making charges of fraud when you really don’t have all the information, as you said yourself?

Is $10,000 too much to charge for an admission, examination, delivery of fetal and placental tissue and pathologist’s services? It sounds like a lot to me, but I don’t have all the information, and it seems as if you don’t either. And you are the “advocate”.

About “upcoding”: Some practitioners needlessly downcode their work, for which they legitimately should code higher levels for service, exactly because they fear someone will accuse them of fraudulent billing. They shouldn’t have to do that.
If their coding office tells them to upcode, they aren’t necessarily advising them to overcode for the work done, either.

Our federal government requires that a standard charge be created for every codable service and that whatever we charge, it must never be lower than what the federal government schedules. So a cash-paying patient, who costs no one anything in lost interest or collections has to pay at least as much as the Medicare patient whose payment can be dragged out months before being paid, if it is paid. Sound unfair? It is. Don’t like it? Write your Congressman.

Should an uninsured patient who is willing to pay in cash in full get at least as low a rate as Medicare? I think so. They should pay less, in fact.

Should an uninsured patient who can’t pay in full but wants to pay in installments have to pay more than Medicare? Maybe. It depends on the terms and the risk. If I as a service provider also have to act as your involuntary lender, after I have delivered your services, I should be compensated for the delay in receiving my pay, and for the fair risk i have to accept of your not paying at all.

Are hospital services and charges high? You bet. But there are things that have to be provided for which the limit on daily room charges under Medicare simply don’t cover: stuff like security, and housekeeping, and about a million other things that are necessary to keep a hospital facility open and running according to OSHA, JCAHO and other accepted standards. So a box of 4×4 Ray-Tex costs $50, because someone will pay for that itemized material, but not for snow shoveling.

Your client used services. They cost money. She should be responsible for the fair charges, even if she doesn’t have an insurance policy to pay for some of that.

Looks like Dr. Elliot forgot to take his Haldol this morning. Straghtjacket anyone?

What a bunch of pathological snivellers inhabit Kevin’s blog. ismd, we just will have to agree to disagree about when civil discourse is appropriate and when rudeness is appropriate. I think the comment section of this blog is certainly a place I’m entitled to call names given the quality of the discourse in general.

As an illustration, our host, Kevin, is often, in my opinion, dishonest in his editorial decisions so this time, I decided to compliment him for highlighting a real issue instead of the red herring of tort reform. I was just trying to offer a little positive reinforcement. While I was composing my comment, one of the common species of whining, lying, jerks made his/her appearance. If you can’t see the lack of compassion, the lack of humanity, and the lack of a clue in that first anonymous comment then all I got to say is years of education and training can make a doctor, but not a human being.

Elliott, nothing you have written here would make me think you have the slightest clue as to the meaning of compassion, or decency or consideration. You present yourself in the most repulsive way possible, unlike the posters you seem to have so much contempt for. Why you would think anyone reading here would find what you say persuasive or appealing is a mystery. You slide into a form of juvenile name-calling that most people who have any sense of self worth have grown out of by the time they are adults. Do you conduct yourself in the same way in person?

And why do you have this fixation with anonymous posting anyway? Do you imagine yourself superior for using a moniker?

“What a bunch of pathological snivellers inhabit Kevin’s blog. ismd, we just will have to agree to disagree about when civil discourse is appropriate and when rudeness is appropriate. I think the comment section of this blog is certainly a place I’m entitled to call names given the quality of the discourse in general.”

Elliott,

If you want to get your point across, knock off the name calling. And, yes, my fellow physicians should stop also. But your earlier post was unbelievable in its plain old meanness. And while we can agree to disagree, not even these comment areas should be inhabited by rude people on either side. And your opinion of “the quality of discourse” is no reason to pursue rudeness.

“If you can’t see the lack of compassion, the lack of humanity, and the lack of a clue in that first anonymous comment then all I got to say is years of education and training can make a doctor, but not a human being.”

I guess my four years as an English minor went to hell. I have no idea where you’re coming from regarding the first anonymous post.

ismd, every regular reader of this blog knows my points by this time so I don’t think that name calling or lack of it is going to change anything (on either side).

Many of the doctors here believe that lawyers are the enemy. They blame those lawyers for causing anguish in their professional lives because of the threat of lawsuits and claim that this threat results in more expensive medical care – so called defensive medicine. A further claim is made that high malpractice insurance rates cause movement of doctors away from certain states and/or specialties and results in poorer care.

I reject these arguments and fail to see any proof. Noone is going to convince me with these fact free posts in this blog and the best research is suspect. The best evidence I have seen so far, the AMA article back in June of this year (Kessler et al), I believe had several methodological errors in how it dealt with the data (specifically how they coded for states that did not change their laws during the study period) and I have not been able to obtain the full database that they ran their regression on. Even if I accepted their results, the strongest effect they could find was 2.7% which, when compared to established research regarding other reasons for doctors practice decision is essentially in the noise.

Others have pointed to truly flawed news articles that show changes in physician population due to tort reform. One article from Texas was so full of errors that it actually showed a greater increase in both absolute and relative terms before tort reform vs. after tort reform in both total numbers and specialties. More than one medical blog posted that article and never retracted. I call that dishonest.

Another line of argument talks ad nauseum about Pennsylvania and varies between outright misrepresentation (regarding number of lawsuits)to ambiguous causality (neurosurgeons in a particular county or deaths due to lack of services). My best review of the literature shows no connection between malpractice rates and health outcomes. The most studied phenomena is C-sections and there the causality, to my mind, goes the other way. That is, the areas with high malpractice rates have higher malpractice rates precisely because the C-section rate is higher. I’ve tried to argue that the adverserial role that doctors adopt towards their patients and the over-medicalization of treatment that occurs through “defensive medicine” is likely to mean that patients are more likely to sue rather than less when bad outcomes result.
Finally, this leads to the question of bad outcomes in general. The idea that the system is flawed because bad outcomes are the best predictors of a lawsuit is ridiculous. The system is designed that way on purpose. First, our legal system is not interested in lawsuits based on potential harm, there has to be actual damages. Second, it is impossible to tell at the start what happened. In so many cases, the first hint to the patient or their family that something went wrong is that soemthing bad happened. Noone volunteers in the medical system that a mistake was made. In fact, evidence shows that incompetent nurses and doctors are known to 90% of the medical people in this country, but less than 10% have ever even voiced that concern informally. Thirdly, even if the system was flawed in the way doctors insist, the best response to that flaw is to reduce bad outcomes. That is precisely what the anesthesiologists did to great success.

Finally, I wish to point out one error made over and over in these comments. If I do nothing else with this post, I will have accomplished something. An ad hominem argument attacks the person as a reason to reject or ingore their argument. If the attack on the person is based on the argument that person made then it is NOT an ad hominem no matter how rude, insulting, or socially unacceptable the name calling. (When I call Dr. Curfman a liar because I believe he lied in his argument – this is not an ad hominem even if it is calculated to be offensive to Dr. Curfman and his supporters.) Learn the difference people.

Elliott:

Your verbose and digressive reply completely evades your disgraceful conduct in this thread and is little more than a lame attempt to justify your behavior by saying the issue you care about are more important than anything you do.

Grow up, why don’t you. Your poor behavior is not excused just because you think the issues you want to talk about are more important.

Not every poster who doesn’t choose to engage a topic on terms you decide is a liar or some other form of dishonest person. Your rambling and digressive reply does nothing to own what should be an acknowledgment of shameful and unjust conduct.

If your ideas are as important as you think they are, submit them for peer-reviewed publication where they can have the exposure you obviously think they deserve.

But can you, Elliott?

“Grow up, why don’t you. Your poor behavior is not excused just because you think the issues you want to talk about are more important.”

I don’t know which anonymouse you are, but considering some of the posts by your anonymouse brethren which you haven’t commented on, the above statement is a little hypocritical.

Liar is mild compared to sodomite, terrorist, etc.

CJD

Maybe I couldn’t find the acutal posting of the bill. Rather than hear about the contents, wouldn’t it be useful to view it for one’s self.

That an epidural was placed for a first trimester spontaneous abortion does not lend credibility to the whole story. Yes, pain is now the fifth vital sign, but the whole reason behind epidural use for delivery is to avoid narcotics transferring to the baby. In this case no live baby means no need for an epidural. Simple intravenous demerol or butorphanol would provide safe, effective and humane care without the risks and cost of an epidural.

The story sounds as if it is fabricated.

Thanks, gasman. Perhaps this was overtreatment; the record says the Anesthesiologist was not in attendance.

This was the code:
01967 Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor).
She had Morphine, Bupivacaine; also Oxytocin and Misoprostol, and a couple of antibiotcs.

No fabrication.

Lin

My ability to challenge begins and ends with the medical record. I cannot challenge “medical necessity” or lack thereof without something in the written documentation. The epidural, therefore, will be paid for by my client. The Doctr’s undocumented time, will not be.

Aggregate profits for U. S. hospitals reached a record $26.3 billion in 2004, so I doubt there will be any guidance from them in coding, or clinical, integrity.